A survey of the opinions of obesity experts the causes and treatment of obesity1’2 A Bray,
Barbara
ABSTRACT
A survey
York,
and James
of opinions
DeLany
on the
causes
and
effec-
tiveness oftreatment ofobesity was carried out on 50 physicians and scientists involved in obesity research. Responses were grouped
by region
dom),
(Europe,
sex, age (30-50
Genetic obesity
factors overall.
bohydrate
causes
as a more
and
than
50 y) and
>
as causes
cycling
United (MD
King-
were
and viewed regional
ofmetabolic and
in the
more
usefulness
im-
exercise
variations
defects
and
in
weight
of diet
in the
treatment ofobesity. The older group of respondents rated lowfat diet more highly as a treatment than did their younger colleagues. All groups viewed serotonergic and thermogenic drugs as effective treatments whose usefulness would increase during the next I 0 years. Am J C/in Nutr 1 992;55: 1 5 1S-4S. KEY
WORDS
Drugs,
United abolic
Kingdom, physical defects, diet
genetics,
North
activity,
America,
carbohydrate
Europe,
craving,
met-
Introduction A number
of hypotheses
development and factors; metabolic
or multiplication;
have
persistence defects;
lack
been
ofobesity. disturbances
of will power;
proposed
to explain
the
Among these are genetic in fat cell metabolism
depression;
indiscretions, tivity, and
particularly carbohydrate craving, repeated dieting. (1-3) Evidence can
to support
or reject
and
dietary
physical macbe marshaled
of these potential causative factors but for obesity have yet to be determined. An equally large number of therapeutic approaches have been used in the treatment of overweight patients. These include behavior modification (4), exercise (5), diets of various types (6), and surgery (7). However, there are few surveys in the literature of the opinions of physicians and scientists working in this field about causes of obesity and the effectiveness of the various treatments in promoting weight loss (8, 9). The assembly of a group of specialists developing new drugs for the treatment of obesity provided an opportunity to examine professional views about causes and potential treatment for obesity (10). This paper presents the results of this survey. unequivocal
Methods
each
mechanisms
and
The study International Am J C/in Nuir
in the
ments
of obesity
meetingjust
individuals
before
was asked
attending
to place
panel the
a mark
of the
line
to the
meeting,
line
at a point appropriate. mark
were
and
treat-
four countries.
Of the
52 completed
line was provided. that
treatment to all partic-
ofcauses
from
satellite
along
and extremely important response would be most beginning
a discussion
by a clinical
questionnaires were obtained. For each question a I 0-cm
The respondent
between
where The
not
important
they believed their distances from the
measured
and
recorded
as the score for each answer. The responses came from physicians and scientists in Europe, Canada, United States, United Kingdom, Australia, and Japan. Although the meeting was held in Japan, only two Japanese surveys were returned and they have been excluded from further analysis. There were 13 questionnaires from Europe, 23 from North America, and 14 from the United
Kingdom
and
in these
categories.
bitrarily
dividing
Australia
and
nonphysician analysis
The effect
they
have
been
examined
by ar50 y of age (n = 18) and those > 50 y (n = 32). There were 8 women among the 50 respondents and a comparison of responses by sex was thus carried out. Finally, the responses of physicians vs the
group
scientists
of variance
of age was also examined
into
was
those
examined.
(ANOVA)
by using
between
Data
30 and
were
the general
analyzed linear
by
models
procedure of the Statistical Analytical Systems program (Statistical Analytical Systems Institute, Cary, NC, Version 6, 1990). Means and standard errors of the mean were calculated by using the least-squares means ([SM) procedure. When significant ANOVA F tests were obtained, means were compared by using the PDIF statement of the LSM procedure. Results Causative
factors
for obesity
The analysis of the questionnaires for causative factors in the development of obesity is summarized in Table 1. The largest expressed differences in opinions were observed in the analysis by sex. In this analysis the women thought that physical
inactivity,
‘From
materials
carbohydrate
the Pennington
craving,
Biomedical
and
Research
repeated
Center,
dieting
Baton
Rouge,
LA.
was carried out at a satellite meeting of the Sixth Congress on Obesity. This satellite was organized 1992;55:151S-4S.
ipants -80
or PhD).
as significantly
There
importance
of obesity
degree
male colleagues
treatment.
ofthe
and
the most important causes of lack of physical activity, car-
weight
did their
effective
the assessment cycling
and
America,
were considered Females viewed
craving,
portant
North
to examine the newer developments in pharmacologic of obesity (9). A questionnaire was made available
Printed
in USA. © 1992 International
2
Address
search Association
reprint
Center,
6400
requests
to GA
Perkins
Road,
for the Study
of Obesity
Bray, Baton
Pennington Rouge,
Biomedical
Re.
LA 70808.
l5lS
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
George
on
l52S
BRAY
TABLE
ET
AL
1
Causative
factors
for the o nset of obesity* Region
Sex
Age United Kingdom
North
Europe
Questionst Numberofrespondents
13
Physical
inactivity
defect
Fat cell defect Repeated dieting (weight-cycling) ±
*
SEM. Means with different
t The number
were
more
colleagues. mension,
important
14
3.94 ± 0.70 6.30 ± 0.53 4.57 ± 0.58 5.73 ± 0.53 7.91 ± 0.43 6.21a ± 0.65 4.42 ± 0.60
5.75 ± 0.92 6.16 ± 0.69 4.29 ± 0.77 5.59 ± 0.70 6.80 ± 0.56
causative
±
± ± ±
3.40 ± 0.87
±
6.06k
±
± 0.80
are significantly
number
factors
±
306b
439b
superscripts
±
± 0.96
± 0.59
listed is the maximum
30-50
than
did
their
male
causation the most
a few differences
TABLE
Americans
than
tended
their
European
42
4.68 0.53 5.3Y 0.39
0.66
±
6.33 0.50 5.23 0.55 5.24 0.50 7.03 0.40 54#{216} 0.64 4.06 0.59 593 0.55
±
±
± ± ± ± ±
±
±
± ± ± ± ±
8
18
32
5.04
4.49 0.88
0.72
6.61 0.66 4.66
±
0.54
± 0.73
±
5.04 0.60
1.1 1
±
±
7.53” 0.83
±
625b
0.44 4.92 0.40 7.01 0.32 5.83 0.51 4.13 0.48 4.68a 0.45
±
± ± ± ±
0.92 6.69 0.84 7.38 0.68 4.63 1.09 3.58 1.01
5.23 ±
±
3#{149}45a
±
MD
6.25
5.8 1 ±
0.66
5.81 ± 0.54
7.13 ± 0.53
7.25
0.43
±
5.52
4.94
± 0.85
± 0.70
4.13 ± 0.79
709b
6.16
± 0.92
± 0.73
as significantly
to view
a lack
colleagues.
ofwill
among
regions.
craving was a more important the other two regions; the United
thought
depression
are
thought
fat-cell
less im-
Three
also observed
were
A metabolic
North
18
4.93 0.91 6.53 0.67 4.47 0.75 6.38 0.68 7.36 0.55 5.06 0.89 3.64 0.84 5.85 0.77
PhD
carbohydrate factor than
by the obesity experts from the United Kingdom and dieting was seen as less important by the North Amer-
group.
viewed
32
4.79
Female
differences
portant repeated
as less important
was
Male
diim-
evident.
ican
defect
responses
y
3.57 ±
0.64
±
0.60
5.62
different.
portant.
of regional
>50
of respondents.
For both sexes, and throughout the genetic factors were viewed as among
In a comparison
y
degree
the
United
was
defects
Europeans etiologic Kingdom
thought causative delegation
less important; and the North Americans were more important than scientists from
Kingdom.
No statistically significant differences were observed when comparing by age, though depression tended to be viewed as
power
more
important
smaller
over
50 y than
as a causative by those under
factor 50 y.
of obesity
in individuals
2
Effectiveness
of treatments
for obesity Region
Europe
Questions Behavior
modification ±
Exercise ±
Surgery ±
Drugs ±
Diet ±
Low carbohydrate
diet ±
Low fat diet ± *
-
±
SEM.
Means
4.71 0.63 5.59 0.68 4.27 0.77 5.33 0.70 7.12ac 0.78 5.20ac 0.68 6.52 0.78
with different
America
30-50
Professio nal degree
Sex
Age United Kingdom
North
>50
y
y
Male
Female
4.98
5.50
5.18
4.94
4.60
5.52
± 0.42
± 0.58
± 0.39
± 0.55
± 0.32
± 0.66
4.88 ± 0.62 5.78 ± 0.73 5.29 ± 0.66
5.59 0.43 4.34 0.50 4.97 0.45 5.51 0.49 3.68 0.43
4.81 0.59 5.40 0.67 5.24 0.61 6.11 0.68 4.72 0.59
± ± ± ±
5.13 0.45 4.56 0.50 4.69 0.46 4.92” 0.52 340b
± ± ±
539bc
± 0.71
±
4#{216}#{216}bC
± ± ± ±
4.OOa ± 0.35
497
5.43
± 0.57
± 0.47
5.41
4.33
4.53
5.20
± 0.38
± 0.84
± 0.65
± 0.53
4.85
5.36
± 0.35
± 0.77
5.57 ± 0.59 5.92 ± 0.64 4.34 ± 0.56 6.31 ± 0.64
5.32
6.29
± 0.40
± 0.82
4.19
4.21
± 0.35
± 0.72
5.16 ± 0.52
6.16
5.21a
669b
5.17
6.73
± 0.71
± 0.49
± 0.68
± 0.40
± 0.82
superscripts
are significantly
different.
5.02 ± 0.43
± 0.72
± 0.62
±
5.1 1 ± 0.52
MD
640b
± 0.45
±
PhD
4.64 ± 0.48
5.69 ± 0.53
4.06 ± 0.47
5.59 ± 0.53
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
Carbohydrate craving Depression leading to overeating Genetic factors Metabolic
23
4.90 ± 1.08 6.84 ± 0.79 5.69 ± 0.88 6. 1 1 ± 0.80 6.86 ± 0.64 6.43a ± 1.02 3.73 ± 0.97 7.22w ± 0.88
ofwill-power
Lack
America
Professional
SURVEY
TABLE 3 Role of drugs in the treatment
OF
OBESITY
153S
EXPERTS
of obesity Professional degree
Region
Age Europe
Questionst
How important
are drugs in treating in your country today?
obesity
3.42
4.25
4.12
± 0.58
± 0.84
± 0.44
7.04
6.95
6.07
± 0.70
± 0.48
± 0.65
drugs ±
(DHEA) ±
(RU486)
I
SEM. Means with different
±
Comparing
groups
differences,
and
number
by professional
again
these
5.74
6.43
± 0.74
± 0.51
± 0.6447
3.55 ±
6.93
6.45 ± 0.80
5.96
0.69
0.39
±
±
MD
4.29 ±0.81 6.83 ± 0.62
1.04
± 0.34
6.10 ±
PhD
3.37 ± 0.62
6.55 ± 0.47
6.57
6.87
5.66
0.86
± 0.67
± 0.54
3.76
2.92
3.59
2.36
2.79
3.15
2.43
3.52
± 0.49
± 0.71
± 0.48
± 0.67
± 0.35
± 0.87
± 0.64
± 0.53
4.01
4.29
4.85
4.70
4.14
5.42
4.98
4.58
± 0.64
± 1.02
± 0.64
± 0.90
± 0.47
± 1.16
± 0.84
± 0.71
5.14
4.20
5.30
4.45
4.94
4.81
4.22
5.53
± 0.62
± 0.85
± 0.58
± 0.81
± 0.44
± 1.04
± 0.76
± 0.65
3.36
3.63
3.44
3.86
3.08
4.21
4.04
3.26
0.60
± 0.97
± 0.64
± 0.81
± 0.37
± 1.19
± 0.76
± 0.70
3.87
3. 15
± 0.67
± 1.05
±
3.23
4.49
3.27
0.66
± 0.87
± 0.48
4.45 ±
1.19
4.08
3.64
± 0.83
± 0.74
different.
of respondents.
degree
differences
5.92
are significantly
superscripts
listed is the maximum
6.47
0.44
± 0.51
±
0.91
±
6.91 ±
Female
showed
were
only
A few
a few
not statistically
sig-
nificant. A defect in fat cells and a metabolic defect were both thought to be more important among nonphysician scientists than among physicians. In contrast, lack of will power and carbohydrate craving were thought to be more important causative factors among physicians.
differences
older group of treatment Among
were
also
apparent
in relation
to age.
The
felt that low-fat diet was more effective as a form for obesity than did their younger colleagues. the physicians there was a suggestion that surgery and
diets, particularly treatments and
nonphysician
the low-carbohydrate drugs less-effective
specialists,
though
diets, treatments
were more-effective than among the
no significant
differences
were
found. Effectiveness Table
of treatments
Role
2 lists the differences
according
to effectiveness
of treat-
ment. Here again, the most differences were observed when comparing the male and female responses. In four of the responses women tended to indicate that individual treatments were
more
These
effective
treatments
difference
cation, thought female
of opinion,
differences
examining nificantly colleagues. dom
exercise, and
and
from
diets
than
effective
the other
by the contingents
two groups. important
mediate
in North
America,
On important
the
other
and hand,
by North
most the
scientists
or British were con-
modification
low-fat
Americans
as sig-
the United
diet than
King-
in the was
they
inter-
ment
of each
perceived
by the
other
to
asked
used
in the
drugs’
Only
three
to report which of eight antiobesity past, giving a rating for their assess-
success.
Fifty
drugs
drugs
were
participants
in treatment
all three were were
evaluated
regions,
in the
had
varied
at present. potential
(Table more
treatment
greatly
participants
with
clear
professional
No significant
norephed-
Table
the small
observation the
10 years
differences
number
of results. of a number
groups,
about
of a variety different
and
interpretation usefulness
3). One
of obesity
gree. As can be seen from drug treatments and thermogenic
experience
optimistic
usefulness
on comparing
of the
and six with phentermine as anreported use of phenylpropanolOverall estimates of the success
not allow potential
age groups,
significantly
percent
ofthe drugs, and within this group =-70% and fluoxetine and 40% had used ma-
of responses involved did The present and future
found
two
were
of obesity
rime, five with amphetamines, tiobesity agents. Eight people amine and of diethylpropion.
the
United
had
had used one or more had used fenfluramine
drugs
was per-
scientists,
important
by
viewed
American and drugs
European
Participants
ofthese found
in particular
from
Behavior by the
the males than the
in the treatment
drugs
zindol.
modifi-
were
European
men.
was a significant behavior
of treatment
responses.
to be least
groups.
extent,
low-carbohydrate
ceived Kingdom.
to a lesser
there
more important than their North Behavior modification, surgery, more
be less
responses where
in estimates
the regional
in general
sidered
corresponding
a low-fat diet, and drugs. On the other hand, that surgery was a more effective treatment contingent.
A few diet
than included
ofdrugs
and both potential
from
that
sexes role
now
in opinions of drug
of
was
than
of they
concerning
treatments
were
by region, age, sex, or de4, participants rated the various
groups
very differently overall. The drugs were rated as potentially
serotonergic the most
drugs useful,
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
7.14 0.79 2.24 0.72 6.04 0.93 5.29 0.89 3.96 0.83 4.55
±
t The number
Male
3.97
Cholecystokinin-agonists
*
y
± 0.85
±
Anti-steroids
>50
3.38
inhibitors
Dihydroepiandrosterone
y
± 0.62
drugs
Thermogenic
30-50
4.15
±
Lipase
United
Kingdom
± 0.91
How important do you think they will be in 10 years? How do you rate the potential usefulness of the following dregs? Serotonergic
North
America
Sex
1 54S
BRAY
TABLE
4
Overall
perception
of potential Dreg
usefulness
of dreg
least-squares
and
means.
5.86 5.31 4.13 3.39 3.27 2.94 Means
with different
abolic
± 0.3l ± 0.32k ±
agonists,
intermediate
(DHEA)
lipase
least
inhibitors,
and
useful, RU
0#{149}33b
± 0.33k ± 0.34k ± 0.33c
in their
superscripts
with
486
chole-
falling
in an
evaluation
on the treatment
contrasts.
One
ofphysician ofobesity
is that
and nonphysician
has provided
regardless
ofthe
basis
viewed the potential for drugs in the next better than they are at the present. They thermogenic velopment.
drugs
as the
major
several
view serotonergic areas
and
for effective
de-
In viewing overall responses on the causes of obesity, there general agreement that genetic factors were extremely important and that fat-cell defects were not. Lack of will power was
ranked
highly
only
tion
considering
completing
the relatively
the survey.
repeated
dieting
power
the
United
King-
mechanisms in obesity significantly from men in must be viewed with caunumber of women (n = 8)
inactivity,
carbohydrate
and,
to a lesser extent,
cycling),
to be more counterparts.
of will
from
small
Physical
(weight
sion were believed among their male importance
by participants
views ofcausative women differed any conclusions
craving,
depres-
important among women No significant difference
was
seen
here,
in contrast
than in the
to findings
in the surveys by Price et al (1 1) and by Maimon et al (12) where men were more likely than women to believe that obese subjects lacked
rate
will
power
depression
and
self-control.
as more
previous reports as stereotypically
The
important
that men were sad (1 1) and
tendency
than
men
for women
to
is supported
by
less likely to view obese patients were far less likely to attribute
emotional problems as a cause of obesity (12), though in a survey of physicians and students in 1969, Maddox and Liederman (8) found
that
tional
factors
96%
of all respondents
of importance
considered
in the etiology
social
other
of effective
treatments.
Exercise,
end
of
fat cells. were no subjects
obesity, women and
to a
for
obesity
than
women.
The
older
members
of the
viewed a low-fat diet as more effective than the younger Surgery tended to be viewed as most effective among the from the United Kingdom, among the older sample, the men, and in the medically qualified group. B
References
was
dom. Several divergent were expressed. First, this category, though
At the
scientist interesting
ofanalysis, all groups 10 years as considerably
potential
components.
lesser extent, behavior modification and a low-fat diet were believed to be much more effective forms oftreatment among the women than the men in this sample. That exercise is regarded as a more effective treatment by the women can be linked to the finding that physical inactivity was considered as a more important cause of obesity by this group. Price et al (1 1) also found that males were less likely to suggest aerobic exercise as sample group. group among
The present
as major
assessment
treatment
position.
Discussion
views
consequences
the spectrum were carbohydrate craving and a defect in Unlike Price et al (1 1) we found that older respondents less likely than younger respondents to believe that obese lacked will power. In parallel with the differing views of the causes for there were also important differences between men and
different.
dihydroepiandrosterone
cystokinin
usefulness
and
of overweight.
emo-
1. Mayer J. Genetic, traumatic and environmental factors in the etiology ofobesity. Physiol Rev 1953;33:472-508. 2. Schwartz H. Never satisfies. A cultural history ofdiets, fantasies &
fat. New York: Doubleday,
1990.
3. Bray GA. Obesity, a disorder ofnutrient partitioning: the Mona Lisa Hypothesis. J Nutr l991;l2l:l 146-62. 4. Foreyt JP, Goodrick OK. Factors common to successful therapy for the obese patient. Med Sci Sports Exerc 199 1;23:292-7. 5. Wilmore JH. Body composition in sport and exercise: directions for future research. Med Sci Sports Exerc l983;15:2l-3l. 6. Frankle RR, Dwyer J, Moragne L, Owen A, eds. Dietary treatment and
prevention
Congress Libbey,
of obesity.
on Obesity,
A satellite
symposium
New York, October
2-4
4th
1983.
International
London:
John
1985.
7. Yale CE. Gastric surgery for morbid obesity. Arch Surg l989;l24: 94 1-7. 8. Maddox GL, Liederman V. Overweight as a social disability with medical implications. J Med Educ 1969;44:2l4-20. 9. Cade J. Management ofweight problems and obesity-knowledge, attitudes and current practice ofgeneral practitioners. Br J Gen Prac 199 l;4 1: 147-50. 10. Bray GA, Inoue S. Pharmacological treatment of obesity. Satellite Symposium to the 6th International Congress ofObesity. Am J Clin Nutr 1992; in press. 1 1. Price JH, Desmond SM, Krol RA, Snyder FF, O’Connell JK. Family practice physicians’ beliefs, attitudes and practices regarding obesity. Am J Prey Med l987;3:339-45. 12. Maiman LA, Wang VL, Becker MH, Finlay J, Simonson M. Attitudes toward obesity and the obese among professionals. J Am Diet Assoc l979;74:33l-6.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
SE ofthe
S
are significantly
degree
Potential
How do you rate the potential usefulness of the following dregs? Serotonergic dregs Thermogenic dregs Cholecystokinin-agonists Lipase inhibitors Anti.steroids (RU486) Dihydroepiandrosterone (DHEA)
AL
In contrast, the effects ofage and the nature ofthe professional showed much less contrast in causative factors. It appeared that most groups viewed genetic factors and their potential met-
treatments*
class
ET
Barbara
ABSTRACT
A survey
York,
and James
of opinions
DeLany
on the
causes
and
effec-
tiveness oftreatment ofobesity was carried out on 50 physicians and scientists involved in obesity research. Responses were grouped
by region
dom),
(Europe,
sex, age (30-50
Genetic obesity
factors overall.
bohydrate
causes
as a more
and
than
50 y) and
>
as causes
cycling
United (MD
King-
were
and viewed regional
ofmetabolic and
in the
more
usefulness
im-
exercise
variations
defects
and
in
weight
of diet
in the
treatment ofobesity. The older group of respondents rated lowfat diet more highly as a treatment than did their younger colleagues. All groups viewed serotonergic and thermogenic drugs as effective treatments whose usefulness would increase during the next I 0 years. Am J C/in Nutr 1 992;55: 1 5 1S-4S. KEY
WORDS
Drugs,
United abolic
Kingdom, physical defects, diet
genetics,
North
activity,
America,
carbohydrate
Europe,
craving,
met-
Introduction A number
of hypotheses
development and factors; metabolic
or multiplication;
have
persistence defects;
lack
been
ofobesity. disturbances
of will power;
proposed
to explain
the
Among these are genetic in fat cell metabolism
depression;
indiscretions, tivity, and
particularly carbohydrate craving, repeated dieting. (1-3) Evidence can
to support
or reject
and
dietary
physical macbe marshaled
of these potential causative factors but for obesity have yet to be determined. An equally large number of therapeutic approaches have been used in the treatment of overweight patients. These include behavior modification (4), exercise (5), diets of various types (6), and surgery (7). However, there are few surveys in the literature of the opinions of physicians and scientists working in this field about causes of obesity and the effectiveness of the various treatments in promoting weight loss (8, 9). The assembly of a group of specialists developing new drugs for the treatment of obesity provided an opportunity to examine professional views about causes and potential treatment for obesity (10). This paper presents the results of this survey. unequivocal
Methods
each
mechanisms
and
The study International Am J C/in Nuir
in the
ments
of obesity
meetingjust
individuals
before
was asked
attending
to place
panel the
a mark
of the
line
to the
meeting,
line
at a point appropriate. mark
were
and
treat-
four countries.
Of the
52 completed
line was provided. that
treatment to all partic-
ofcauses
from
satellite
along
and extremely important response would be most beginning
a discussion
by a clinical
questionnaires were obtained. For each question a I 0-cm
The respondent
between
where The
not
important
they believed their distances from the
measured
and
recorded
as the score for each answer. The responses came from physicians and scientists in Europe, Canada, United States, United Kingdom, Australia, and Japan. Although the meeting was held in Japan, only two Japanese surveys were returned and they have been excluded from further analysis. There were 13 questionnaires from Europe, 23 from North America, and 14 from the United
Kingdom
and
in these
categories.
bitrarily
dividing
Australia
and
nonphysician analysis
The effect
they
have
been
examined
by ar50 y of age (n = 18) and those > 50 y (n = 32). There were 8 women among the 50 respondents and a comparison of responses by sex was thus carried out. Finally, the responses of physicians vs the
group
scientists
of variance
of age was also examined
into
was
those
examined.
(ANOVA)
by using
between
Data
30 and
were
the general
analyzed linear
by
models
procedure of the Statistical Analytical Systems program (Statistical Analytical Systems Institute, Cary, NC, Version 6, 1990). Means and standard errors of the mean were calculated by using the least-squares means ([SM) procedure. When significant ANOVA F tests were obtained, means were compared by using the PDIF statement of the LSM procedure. Results Causative
factors
for obesity
The analysis of the questionnaires for causative factors in the development of obesity is summarized in Table 1. The largest expressed differences in opinions were observed in the analysis by sex. In this analysis the women thought that physical
inactivity,
‘From
materials
carbohydrate
the Pennington
craving,
Biomedical
and
Research
repeated
Center,
dieting
Baton
Rouge,
LA.
was carried out at a satellite meeting of the Sixth Congress on Obesity. This satellite was organized 1992;55:151S-4S.
ipants -80
or PhD).
as significantly
There
importance
of obesity
degree
male colleagues
treatment.
ofthe
and
the most important causes of lack of physical activity, car-
weight
did their
effective
the assessment cycling
and
America,
were considered Females viewed
craving,
portant
North
to examine the newer developments in pharmacologic of obesity (9). A questionnaire was made available
Printed
in USA. © 1992 International
2
Address
search Association
reprint
Center,
6400
requests
to GA
Perkins
Road,
for the Study
of Obesity
Bray, Baton
Pennington Rouge,
Biomedical
Re.
LA 70808.
l5lS
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
George
on
l52S
BRAY
TABLE
ET
AL
1
Causative
factors
for the o nset of obesity* Region
Sex
Age United Kingdom
North
Europe
Questionst Numberofrespondents
13
Physical
inactivity
defect
Fat cell defect Repeated dieting (weight-cycling) ±
*
SEM. Means with different
t The number
were
more
colleagues. mension,
important
14
3.94 ± 0.70 6.30 ± 0.53 4.57 ± 0.58 5.73 ± 0.53 7.91 ± 0.43 6.21a ± 0.65 4.42 ± 0.60
5.75 ± 0.92 6.16 ± 0.69 4.29 ± 0.77 5.59 ± 0.70 6.80 ± 0.56
causative
±
± ± ±
3.40 ± 0.87
±
6.06k
±
± 0.80
are significantly
number
factors
±
306b
439b
superscripts
±
± 0.96
± 0.59
listed is the maximum
30-50
than
did
their
male
causation the most
a few differences
TABLE
Americans
than
tended
their
European
42
4.68 0.53 5.3Y 0.39
0.66
±
6.33 0.50 5.23 0.55 5.24 0.50 7.03 0.40 54#{216} 0.64 4.06 0.59 593 0.55
±
±
± ± ± ± ±
±
±
± ± ± ± ±
8
18
32
5.04
4.49 0.88
0.72
6.61 0.66 4.66
±
0.54
± 0.73
±
5.04 0.60
1.1 1
±
±
7.53” 0.83
±
625b
0.44 4.92 0.40 7.01 0.32 5.83 0.51 4.13 0.48 4.68a 0.45
±
± ± ± ±
0.92 6.69 0.84 7.38 0.68 4.63 1.09 3.58 1.01
5.23 ±
±
3#{149}45a
±
MD
6.25
5.8 1 ±
0.66
5.81 ± 0.54
7.13 ± 0.53
7.25
0.43
±
5.52
4.94
± 0.85
± 0.70
4.13 ± 0.79
709b
6.16
± 0.92
± 0.73
as significantly
to view
a lack
colleagues.
ofwill
among
regions.
craving was a more important the other two regions; the United
thought
depression
are
thought
fat-cell
less im-
Three
also observed
were
A metabolic
North
18
4.93 0.91 6.53 0.67 4.47 0.75 6.38 0.68 7.36 0.55 5.06 0.89 3.64 0.84 5.85 0.77
PhD
carbohydrate factor than
by the obesity experts from the United Kingdom and dieting was seen as less important by the North Amer-
group.
viewed
32
4.79
Female
differences
portant repeated
as less important
was
Male
diim-
evident.
ican
defect
responses
y
3.57 ±
0.64
±
0.60
5.62
different.
portant.
of regional
>50
of respondents.
For both sexes, and throughout the genetic factors were viewed as among
In a comparison
y
degree
the
United
was
defects
Europeans etiologic Kingdom
thought causative delegation
less important; and the North Americans were more important than scientists from
Kingdom.
No statistically significant differences were observed when comparing by age, though depression tended to be viewed as
power
more
important
smaller
over
50 y than
as a causative by those under
factor 50 y.
of obesity
in individuals
2
Effectiveness
of treatments
for obesity Region
Europe
Questions Behavior
modification ±
Exercise ±
Surgery ±
Drugs ±
Diet ±
Low carbohydrate
diet ±
Low fat diet ± *
-
±
SEM.
Means
4.71 0.63 5.59 0.68 4.27 0.77 5.33 0.70 7.12ac 0.78 5.20ac 0.68 6.52 0.78
with different
America
30-50
Professio nal degree
Sex
Age United Kingdom
North
>50
y
y
Male
Female
4.98
5.50
5.18
4.94
4.60
5.52
± 0.42
± 0.58
± 0.39
± 0.55
± 0.32
± 0.66
4.88 ± 0.62 5.78 ± 0.73 5.29 ± 0.66
5.59 0.43 4.34 0.50 4.97 0.45 5.51 0.49 3.68 0.43
4.81 0.59 5.40 0.67 5.24 0.61 6.11 0.68 4.72 0.59
± ± ± ±
5.13 0.45 4.56 0.50 4.69 0.46 4.92” 0.52 340b
± ± ±
539bc
± 0.71
±
4#{216}#{216}bC
± ± ± ±
4.OOa ± 0.35
497
5.43
± 0.57
± 0.47
5.41
4.33
4.53
5.20
± 0.38
± 0.84
± 0.65
± 0.53
4.85
5.36
± 0.35
± 0.77
5.57 ± 0.59 5.92 ± 0.64 4.34 ± 0.56 6.31 ± 0.64
5.32
6.29
± 0.40
± 0.82
4.19
4.21
± 0.35
± 0.72
5.16 ± 0.52
6.16
5.21a
669b
5.17
6.73
± 0.71
± 0.49
± 0.68
± 0.40
± 0.82
superscripts
are significantly
different.
5.02 ± 0.43
± 0.72
± 0.62
±
5.1 1 ± 0.52
MD
640b
± 0.45
±
PhD
4.64 ± 0.48
5.69 ± 0.53
4.06 ± 0.47
5.59 ± 0.53
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
Carbohydrate craving Depression leading to overeating Genetic factors Metabolic
23
4.90 ± 1.08 6.84 ± 0.79 5.69 ± 0.88 6. 1 1 ± 0.80 6.86 ± 0.64 6.43a ± 1.02 3.73 ± 0.97 7.22w ± 0.88
ofwill-power
Lack
America
Professional
SURVEY
TABLE 3 Role of drugs in the treatment
OF
OBESITY
153S
EXPERTS
of obesity Professional degree
Region
Age Europe
Questionst
How important
are drugs in treating in your country today?
obesity
3.42
4.25
4.12
± 0.58
± 0.84
± 0.44
7.04
6.95
6.07
± 0.70
± 0.48
± 0.65
drugs ±
(DHEA) ±
(RU486)
I
SEM. Means with different
±
Comparing
groups
differences,
and
number
by professional
again
these
5.74
6.43
± 0.74
± 0.51
± 0.6447
3.55 ±
6.93
6.45 ± 0.80
5.96
0.69
0.39
±
±
MD
4.29 ±0.81 6.83 ± 0.62
1.04
± 0.34
6.10 ±
PhD
3.37 ± 0.62
6.55 ± 0.47
6.57
6.87
5.66
0.86
± 0.67
± 0.54
3.76
2.92
3.59
2.36
2.79
3.15
2.43
3.52
± 0.49
± 0.71
± 0.48
± 0.67
± 0.35
± 0.87
± 0.64
± 0.53
4.01
4.29
4.85
4.70
4.14
5.42
4.98
4.58
± 0.64
± 1.02
± 0.64
± 0.90
± 0.47
± 1.16
± 0.84
± 0.71
5.14
4.20
5.30
4.45
4.94
4.81
4.22
5.53
± 0.62
± 0.85
± 0.58
± 0.81
± 0.44
± 1.04
± 0.76
± 0.65
3.36
3.63
3.44
3.86
3.08
4.21
4.04
3.26
0.60
± 0.97
± 0.64
± 0.81
± 0.37
± 1.19
± 0.76
± 0.70
3.87
3. 15
± 0.67
± 1.05
±
3.23
4.49
3.27
0.66
± 0.87
± 0.48
4.45 ±
1.19
4.08
3.64
± 0.83
± 0.74
different.
of respondents.
degree
differences
5.92
are significantly
superscripts
listed is the maximum
6.47
0.44
± 0.51
±
0.91
±
6.91 ±
Female
showed
were
only
A few
a few
not statistically
sig-
nificant. A defect in fat cells and a metabolic defect were both thought to be more important among nonphysician scientists than among physicians. In contrast, lack of will power and carbohydrate craving were thought to be more important causative factors among physicians.
differences
older group of treatment Among
were
also
apparent
in relation
to age.
The
felt that low-fat diet was more effective as a form for obesity than did their younger colleagues. the physicians there was a suggestion that surgery and
diets, particularly treatments and
nonphysician
the low-carbohydrate drugs less-effective
specialists,
though
diets, treatments
were more-effective than among the
no significant
differences
were
found. Effectiveness Table
of treatments
Role
2 lists the differences
according
to effectiveness
of treat-
ment. Here again, the most differences were observed when comparing the male and female responses. In four of the responses women tended to indicate that individual treatments were
more
These
effective
treatments
difference
cation, thought female
of opinion,
differences
examining nificantly colleagues. dom
exercise, and
and
from
diets
than
effective
the other
by the contingents
two groups. important
mediate
in North
America,
On important
the
other
and hand,
by North
most the
scientists
or British were con-
modification
low-fat
Americans
as sig-
the United
diet than
King-
in the was
they
inter-
ment
of each
perceived
by the
other
to
asked
used
in the
drugs’
Only
three
to report which of eight antiobesity past, giving a rating for their assess-
success.
Fifty
drugs
drugs
were
participants
in treatment
all three were were
evaluated
regions,
in the
had
varied
at present. potential
(Table more
treatment
greatly
participants
with
clear
professional
No significant
norephed-
Table
the small
observation the
10 years
differences
number
of results. of a number
groups,
about
of a variety different
and
interpretation usefulness
3). One
of obesity
gree. As can be seen from drug treatments and thermogenic
experience
optimistic
usefulness
on comparing
of the
and six with phentermine as anreported use of phenylpropanolOverall estimates of the success
not allow potential
age groups,
significantly
percent
ofthe drugs, and within this group =-70% and fluoxetine and 40% had used ma-
of responses involved did The present and future
found
two
were
of obesity
rime, five with amphetamines, tiobesity agents. Eight people amine and of diethylpropion.
the
United
had
had used one or more had used fenfluramine
drugs
was per-
scientists,
important
by
viewed
American and drugs
European
Participants
ofthese found
in particular
from
Behavior by the
the males than the
in the treatment
drugs
zindol.
modifi-
were
European
men.
was a significant behavior
of treatment
responses.
to be least
groups.
extent,
low-carbohydrate
ceived Kingdom.
to a lesser
there
more important than their North Behavior modification, surgery, more
be less
responses where
in estimates
the regional
in general
sidered
corresponding
a low-fat diet, and drugs. On the other hand, that surgery was a more effective treatment contingent.
A few diet
than included
ofdrugs
and both potential
from
that
sexes role
now
in opinions of drug
of
was
than
of they
concerning
treatments
were
by region, age, sex, or de4, participants rated the various
groups
very differently overall. The drugs were rated as potentially
serotonergic the most
drugs useful,
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
7.14 0.79 2.24 0.72 6.04 0.93 5.29 0.89 3.96 0.83 4.55
±
t The number
Male
3.97
Cholecystokinin-agonists
*
y
± 0.85
±
Anti-steroids
>50
3.38
inhibitors
Dihydroepiandrosterone
y
± 0.62
drugs
Thermogenic
30-50
4.15
±
Lipase
United
Kingdom
± 0.91
How important do you think they will be in 10 years? How do you rate the potential usefulness of the following dregs? Serotonergic
North
America
Sex
1 54S
BRAY
TABLE
4
Overall
perception
of potential Dreg
usefulness
of dreg
least-squares
and
means.
5.86 5.31 4.13 3.39 3.27 2.94 Means
with different
abolic
± 0.3l ± 0.32k ±
agonists,
intermediate
(DHEA)
lipase
least
inhibitors,
and
useful, RU
0#{149}33b
± 0.33k ± 0.34k ± 0.33c
in their
superscripts
with
486
chole-
falling
in an
evaluation
on the treatment
contrasts.
One
ofphysician ofobesity
is that
and nonphysician
has provided
regardless
ofthe
basis
viewed the potential for drugs in the next better than they are at the present. They thermogenic velopment.
drugs
as the
major
several
view serotonergic areas
and
for effective
de-
In viewing overall responses on the causes of obesity, there general agreement that genetic factors were extremely important and that fat-cell defects were not. Lack of will power was
ranked
highly
only
tion
considering
completing
the relatively
the survey.
repeated
dieting
power
the
United
King-
mechanisms in obesity significantly from men in must be viewed with caunumber of women (n = 8)
inactivity,
carbohydrate
and,
to a lesser extent,
cycling),
to be more counterparts.
of will
from
small
Physical
(weight
sion were believed among their male importance
by participants
views ofcausative women differed any conclusions
craving,
depres-
important among women No significant difference
was
seen
here,
in contrast
than in the
to findings
in the surveys by Price et al (1 1) and by Maimon et al (12) where men were more likely than women to believe that obese subjects lacked
rate
will
power
depression
and
self-control.
as more
previous reports as stereotypically
The
important
that men were sad (1 1) and
tendency
than
men
for women
to
is supported
by
less likely to view obese patients were far less likely to attribute
emotional problems as a cause of obesity (12), though in a survey of physicians and students in 1969, Maddox and Liederman (8) found
that
tional
factors
96%
of all respondents
of importance
considered
in the etiology
social
other
of effective
treatments.
Exercise,
end
of
fat cells. were no subjects
obesity, women and
to a
for
obesity
than
women.
The
older
members
of the
viewed a low-fat diet as more effective than the younger Surgery tended to be viewed as most effective among the from the United Kingdom, among the older sample, the men, and in the medically qualified group. B
References
was
dom. Several divergent were expressed. First, this category, though
At the
scientist interesting
ofanalysis, all groups 10 years as considerably
potential
components.
lesser extent, behavior modification and a low-fat diet were believed to be much more effective forms oftreatment among the women than the men in this sample. That exercise is regarded as a more effective treatment by the women can be linked to the finding that physical inactivity was considered as a more important cause of obesity by this group. Price et al (1 1) also found that males were less likely to suggest aerobic exercise as sample group. group among
The present
as major
assessment
treatment
position.
Discussion
views
consequences
the spectrum were carbohydrate craving and a defect in Unlike Price et al (1 1) we found that older respondents less likely than younger respondents to believe that obese lacked will power. In parallel with the differing views of the causes for there were also important differences between men and
different.
dihydroepiandrosterone
cystokinin
usefulness
and
of overweight.
emo-
1. Mayer J. Genetic, traumatic and environmental factors in the etiology ofobesity. Physiol Rev 1953;33:472-508. 2. Schwartz H. Never satisfies. A cultural history ofdiets, fantasies &
fat. New York: Doubleday,
1990.
3. Bray GA. Obesity, a disorder ofnutrient partitioning: the Mona Lisa Hypothesis. J Nutr l991;l2l:l 146-62. 4. Foreyt JP, Goodrick OK. Factors common to successful therapy for the obese patient. Med Sci Sports Exerc 199 1;23:292-7. 5. Wilmore JH. Body composition in sport and exercise: directions for future research. Med Sci Sports Exerc l983;15:2l-3l. 6. Frankle RR, Dwyer J, Moragne L, Owen A, eds. Dietary treatment and
prevention
Congress Libbey,
of obesity.
on Obesity,
A satellite
symposium
New York, October
2-4
4th
1983.
International
London:
John
1985.
7. Yale CE. Gastric surgery for morbid obesity. Arch Surg l989;l24: 94 1-7. 8. Maddox GL, Liederman V. Overweight as a social disability with medical implications. J Med Educ 1969;44:2l4-20. 9. Cade J. Management ofweight problems and obesity-knowledge, attitudes and current practice ofgeneral practitioners. Br J Gen Prac 199 l;4 1: 147-50. 10. Bray GA, Inoue S. Pharmacological treatment of obesity. Satellite Symposium to the 6th International Congress ofObesity. Am J Clin Nutr 1992; in press. 1 1. Price JH, Desmond SM, Krol RA, Snyder FF, O’Connell JK. Family practice physicians’ beliefs, attitudes and practices regarding obesity. Am J Prey Med l987;3:339-45. 12. Maiman LA, Wang VL, Becker MH, Finlay J, Simonson M. Attitudes toward obesity and the obese among professionals. J Am Diet Assoc l979;74:33l-6.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/1/151S/4715218 by guest on 20 November 2018
SE ofthe
S
are significantly
degree
Potential
How do you rate the potential usefulness of the following dregs? Serotonergic dregs Thermogenic dregs Cholecystokinin-agonists Lipase inhibitors Anti.steroids (RU486) Dihydroepiandrosterone (DHEA)
AL
In contrast, the effects ofage and the nature ofthe professional showed much less contrast in causative factors. It appeared that most groups viewed genetic factors and their potential met-
treatments*
class
ET
